Comparison of Acute Kidney Injury During Treatment with Vancomycin in Combination with PiperacillinTazobactam or Cefepime Diane M. Gomes,1 Carmen Smotherman,2 Amy Birch,1,3 Lori Dupree,1,3 Bethany J. Della Vecchia,1,3 Dale F. Kraemer,2,4 and Christopher A. Jankowski1,3* 1
UF Health Jacksonville, Jacksonville, Florida; 2Center for Health Equity and Quality Research, Jacksonville, Florida; 3University of Florida College of Pharmacy, Jacksonville, Florida; 4Department of Neurology, University of Florida, Jacksonville, Florida
STUDY OBJECTIVE To evaluate the observed incidence of acute kidney injury (AKI) in adult patients receiving either piperacillin-tazobactam and vancomycin or cefepime-vancomycin for more than 48 hours. DESIGN Retrospective matched cohort. SETTING Large academic medical center. PATIENTS Adult patients without preexisting renal dysfunction admitted over an 8-month time period who received either the combination of piperacillin-tazobactam and vancomycin or cefepime-vancomycin for more than 48 hours were evaluated for AKI, defined by the Acute Kidney Injury Network criteria. MEASUREMENTS AND MAIN RESULTS A total of 224 patients receiving either antimicrobial combination were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (34.8%) compared with the cefepime-vancomycin group (12.5%) in the unmatched analysis (p48 h apart: 6 Missing data: 3 Incarcerated: 5 Meningitis: 1
Included (n = 112)
Cefepime and Vancomycin (n = 361)
Excluded (n = 249) Renal*: 110 Combination < 48 h: 90 Inappropriately drawn trough: 18 Antibiotics started >48 h apart: 16 Missing data: 7 Incarcerated: 5 Meningitis: 2 Neutropenic fever: 1
Included (n = 112)
Figure 1. Study design. *Receiving dialysis, documented history of chronic kidney disease (≥ Stage III), structural kidney disease (e.g. one kidney, kidney transplant, kidney tumor), documented renal insufficiency (Clcr < 60 mL/min)
13.06 mg/L (SD = 6.08 mg/L) in the piperacillin-tazobactam and vancomycin and cefepimevancomycin groups, respectively (p=0.58). There were more pharmacist-managed pharmacokinetics consultations for patients in the piperacillintazobactam and vancomycin group compared with patients in the cefepime-vancomycin group during the study period (40% vs 17%, respectively, p=0.0001). No statistically significant differences were found between each concomitant nephrotoxic agent (e.g., ACE-I, IV contrast, amphotericin, acyclovir, chemotherapy, or aminoglycosides) with the exception of NSAIDs (piperacillin-tazobactam and vancomycin 10.7% vs 22.3% cefepime-vancomycin, p=0.019). Between the piperacillin-tazobactam and vancomycin and the cefepime-vancomycin groups, no differences were found in mean LOS (18.5 vs 25.2 days, p=0.2) and infection-related LOS (13.1 days in both groups; p=0.70). Mean days of antimicrobial therapy were significantly higher in the piperacillin-tazobactam and vancomycin group than in the cefepime-vancomycin group (7.1 vs 6.7, respectively, p=0.003) before propensity score matching was conducted. For unmatched data, the incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (34.8%) compared with the cefepime-vancomycin group (12.5%) (odds ratio [OR] 3.74, 95% confidence interval [CI] 1.89–7.39, p
UF Health Jacksonville, Jacksonville, Florida; 2Center for Health Equity and Quality Research, Jacksonville, Florida; 3University of Florida College of Pharmacy, Jacksonville, Florida; 4Department of Neurology, University of Florida, Jacksonville, Florida
STUDY OBJECTIVE To evaluate the observed incidence of acute kidney injury (AKI) in adult patients receiving either piperacillin-tazobactam and vancomycin or cefepime-vancomycin for more than 48 hours. DESIGN Retrospective matched cohort. SETTING Large academic medical center. PATIENTS Adult patients without preexisting renal dysfunction admitted over an 8-month time period who received either the combination of piperacillin-tazobactam and vancomycin or cefepime-vancomycin for more than 48 hours were evaluated for AKI, defined by the Acute Kidney Injury Network criteria. MEASUREMENTS AND MAIN RESULTS A total of 224 patients receiving either antimicrobial combination were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (34.8%) compared with the cefepime-vancomycin group (12.5%) in the unmatched analysis (p48 h apart: 6 Missing data: 3 Incarcerated: 5 Meningitis: 1
Included (n = 112)
Cefepime and Vancomycin (n = 361)
Excluded (n = 249) Renal*: 110 Combination < 48 h: 90 Inappropriately drawn trough: 18 Antibiotics started >48 h apart: 16 Missing data: 7 Incarcerated: 5 Meningitis: 2 Neutropenic fever: 1
Included (n = 112)
Figure 1. Study design. *Receiving dialysis, documented history of chronic kidney disease (≥ Stage III), structural kidney disease (e.g. one kidney, kidney transplant, kidney tumor), documented renal insufficiency (Clcr < 60 mL/min)
13.06 mg/L (SD = 6.08 mg/L) in the piperacillin-tazobactam and vancomycin and cefepimevancomycin groups, respectively (p=0.58). There were more pharmacist-managed pharmacokinetics consultations for patients in the piperacillintazobactam and vancomycin group compared with patients in the cefepime-vancomycin group during the study period (40% vs 17%, respectively, p=0.0001). No statistically significant differences were found between each concomitant nephrotoxic agent (e.g., ACE-I, IV contrast, amphotericin, acyclovir, chemotherapy, or aminoglycosides) with the exception of NSAIDs (piperacillin-tazobactam and vancomycin 10.7% vs 22.3% cefepime-vancomycin, p=0.019). Between the piperacillin-tazobactam and vancomycin and the cefepime-vancomycin groups, no differences were found in mean LOS (18.5 vs 25.2 days, p=0.2) and infection-related LOS (13.1 days in both groups; p=0.70). Mean days of antimicrobial therapy were significantly higher in the piperacillin-tazobactam and vancomycin group than in the cefepime-vancomycin group (7.1 vs 6.7, respectively, p=0.003) before propensity score matching was conducted. For unmatched data, the incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (34.8%) compared with the cefepime-vancomycin group (12.5%) (odds ratio [OR] 3.74, 95% confidence interval [CI] 1.89–7.39, p
